Transcript Cardiopulmonary Resuscitation

Cardiopulmonary
Resuscitation
Dr. Kailash Kumar Goyal
• Defined as an attempt to restore spontaneous
circulation after a person goes in sudden cardiac
arrest(SCA).
• Can also be defined as a series of lifesaving actions
that improve the chance of survival following
cardiac arrest
• Sudden Cardiac Arrest- Defined as abrupt
cessation of cardiac mechanical function, which
may be reversible by a prompt intervention but will
lead to death in its absence.
Types (forms) of
cardiac arrest:
1) Asystole
(Isoelectric line).
2 Ventricular
fibrillation (VF).
3) Ventricular
tachycardia (VT).
4) Pulseless
electrical activity(PEA)
BASIC LIFE SUPPORT( BLS)
• Circulation
• Airway
• Breathing
ADVANCED CARDIAC LIFE
SUPPORT(ACLS)
• Includes a variety of interventions including
airway intubation, mechanical ventilation and
drugs given during cardiac arrest.
CHAIN OF SURVIVAL
• SCA continues to be a leading cause of death in
many parts of the world.
• SCA has many etiologies (ie, cardiac or non cardiac
causes), circumstances (eg, witnessed or
unwitnessed), and settings (eg, out-of-hospital or
in-hospital).
• This heterogeneity suggests that a single approach
to resuscitation is not practical, but a core set of
actions provides a universal strategy for achieving
successful resuscitation. These actions are termed
the links in the “Chain of Survival.”
Chain of Survival
These include:•
Early recognition & call for help: to prevent cardiac arrest.
•
Early CPR (with minimal interruptions): to buy time.
•
Early defibrillation: to restart the heart.
•
Post resuscitation care: to restore quality of life & minimize
neurological insult.
Sequence of steps of CPR
Early Recognition of sudden cardiac arrest (SCA)
• Unresponsiveness- gently tap the patient and check for response
• Breathing-lack of breathing or abnormal breathing (gasping)
Activating Emergency Response System
• Call for help
• Arrange for defibrillator
Check Pulse
• Central Pulse: Carotid or femoral
• Pulse should be checked for not more than 10 seconds
Simplified adult BLS algorithm.
Berg R A et al. Circulation. 2010;122:S685-S705
Copyright © American Heart Association, Inc. All rights reserved.
Chest compressions
• Circulation
Positioning:
 Person should be lied on hard and flat surface.
 Rescuer kneels beside victim.
 During compressions arms should be kept straight, elbows
locked and shoulder directly above the hand.
 Heel of the dominant hand is placed on the lower half of
victim’s chest, between the nipples. Heel of second hand is
placed on top of the first hand so the hands are overlapped and
parallel.
 Fingers are interlocked.
• On correct positioning, straight downward thrust is
given on sternum depressing it 2 inches (5 cm) in
adults and then allowing to return to its normal
position.
• Compression rate – At least 100 per minute in single
or two person CPR.
• Compression-Ventilation ratio of 30:2 should be
maintained with minimal interruption in chest
compressions for rescue breaths.
• Compression-relaxation should be 50:50
Performing Infant Chest Compressions
Position the infant on a firm
surface while maintaining the
airway. Place two fingers in the
middle of the sternum just below
a line between the nipples.
Use two fingers to compress the
chest one third to one half its depth
at a rate of at least 100 per minute.
Allow the sternum to return to its
normal position between
compressions.
Physiology of Compressions
Cardiac
Pump
Mechanism
Thoracic
Pump
Mechanism
• Blood is ejected as a direct result of compression of heart
between sternum and vertebral column.
• Increasing intrathoracic pressure develops a peripheral
arteriovenous pressure difference that permits blood to
flow forward in extrathoracic vascular system.
Adequacy of compressions
Coronary Perfusion Pressure
PETCO2
Scvo2
PETCO2 >10mm
Hg indicates
good quality
chest
compressions
If Scvo2 < 30%
then attempts to
improve the
quality of CPR
should be done
Difference between Aortic
Diastolic Pressure and the
right atrial diastolic pressure.
Arterial diastolic pressure in
the radial, brachial or femoral
artery is a good indicator of
CPP. Arterial diastolic pressure
of >20mm hg is an indicator of
adequate chest compressions.
AIRWAY
• After initiation of chest compressions, airway
is evaluated and patency is established by a
number of different maneuvers.
This maneuver causes anterior displacement of the
tongue
Make a fist with one hand.
Lean the person slightly
forward and stand behind
him or her.
Put your arms around the
person and grasp your fist
with other hand just
below the center of rib
cage.
Make a quick, hard
movement inward and
upward.
Heimlich Maneuver
• Can also be done in lying down position.
Heimlich Maneuver
• In infants this can be done by a series of blows
on the back and chest thrusts.
Advanced techniques for airway
•
•
•
•
•
•
Facemask
Oropharyngeal airway
Nasopharyngeal airway
Laryngeal mask
Endotracheal tube
Tracheostomy
Endotracheal Intubation
• Indications:(1) The inability of the provider to ventilate the
unconscious patient adequately with a bag and mask
(2)The absence of airway protective reflexes (coma
or cardiac arrest).
The provider must have appropriate
training and experience in endotracheal intubation.
Verify the tube position
1) Clinical assessment:• Visualizing chest expansion bilaterally
• Listening over the epigastrium (breath sounds
should not be heard)
• Listening over the lung fields bilaterally (breath
sounds should be equal and adequate)
2) Devices:• Exhaled CO2 Detectors :Detection of exhaled CO2 is one of several
independent methods of confirming endotracheal tube
position.
100% sensitivity and 100% specificity in
identifying correct endotracheal tube placement.
Recommended as the most reliable method of
confirming and monitoring correct placement of an
endotracheal tube.
• Esophageal Detector Devices(EDD):Consists of a bulb that is compressed and
attached to the endotracheal tube.
If the tube is in the esophagus the suction
created by the EDD collapses the lumen of the
esophagus or pull the esophageal tissue against the
tip of the tube, and the bulb does not re-expand.
• Accuracy of this device does not exceed that of
auscultation and direct visualization for confirming
the tracheal position of an endotracheal tube.
• Can be used as the initial method for confirming
correct tube placement in addition to clinical
assessment when waveform capnography is not
available.
Rescue breaths
A trained rescuer should deliver rescue breaths
by mouth-to-mouth or bag-mask to provide
oxygenation and ventilation, as follows:
• Deliver each rescue breath over 1 second
• Give a sufficient tidal volume to produce visible
chest rise.
• Use a compression to ventilation ratio of 30 chest
compressions to 2 ventilations.
Basic techniques
1) Mouth to mouth breathing:
With the airway held open, pinch the nostrils
closed, take a deep breath and seal your lips over he
patients mouth.
Blow steadily into the patients mouth
watching the chest rise as if the patient was taking a
deep breath
Basic techniques
2) Mouth to nose breathing: seal the mouth
shut and breathe steadily though the nose.
3) Mouth to mouth and nose: is used in infants
and small children.
Expired air contains 16% O2, So supplemental
100% O2 should be used as soon as possible.
Advanced techniques
1) Self-inflating resuscitation bag (Ambu bag):
•
When used without a source of O2 (room
air) gives 21% O2.
•
When connected to a source of O2 (10-15
L/min) gives 45% O2.
•
If a reservoir bag is added it can give up
to 85% O2.
2) Mechanical ventilator
Defibrillation
Defibrillation involves delivery of current through the chest
and to the heart to depolarise myocardial cells
simultaneously and eliminate ventricular fibrillation
• Indications of defibrillation: ventricular fibrillation
and pulseless ventricular tachycardia.
• Shock should be delivered within 3 minutes of
arrest.
• Defibrillators deliver energy either in monophasic
or biphasic waveforms.
• Biphasic defibrillators are recommended as they
achieve the same degree of success with less
energy thereby less myocardial damage.
AUTOMATED EXTERNAL DEFIBRILLATOR
(AED)
• Automated External Defibrillators are computerised
automatic defibrillator which use voice and visual
prompts to guide lay rescuers and healthcare
providers to safely defibrillate.
• They are capable of differentiating shockable and
non-shockable rhythm.
• They can be placed in public places and used by the
community
AUTOMATED EXTERNAL DEFIBRILLATOR
(AED)
• When using AED, one electrode pad is placed
beside the upper right sternal border, just below the
clavicle and the other electrode pad is placed just
lateral to left nipple with top of the pad a few inches
below axilla.
• Alternative positions: anterior-posterior, anteriorleft infrascapular, anterior-right infrascapular.
AUTOMATED EXTERNAL DEFIBRILLATOR (AED)
• A single shock followed by immediate resumption of
chest compression is recommended.
• Shock energy:
– Biphasic: 200 joules or specified by the
manufacturer
– Monophasic : 360 joules
• There is no evidence that increasing the energy level in
successive shocks is more effective than maintaining
the energy level of the initial shock.
Drug Administration
Peripheral
Intraosseous
Endotracheal
Preferred site as
cannulation does
not hinder CPR.
Drugs are given as bolus followed
by 20 ml of intravenous fluid and
extremity elevated for 10 to 20
seconds.
Drug is delivered by puncturing
the marrow cavity (usually in
the sternum)
Atropine,
Epinephrine,
Vasopressin and
Lidocaine can be
given.
Dose should be 2
to 2.5 times the
recommended
intravenous dose
All drug should be
diluted into 10 ml
of water or
isotonic saline.
Vasopressor Drugs
Epinephrine
Vasopressin
• It is a b receptor agonist in low doses and an a receptor agonist in high doses.
• Beneficial during cardiac arrest mainly because of it’s a receptor properties
• It increases myocardial oxygen consumption by increasing heart rate and
afterload.
• Dose: 1 mg every 3-5 minutes in adults.
• Can be given endotracheally.
• It is a non adrenergic vasoconstrictor that acts by direct stimulation of smooth
muscle vasopressin 1 receptors leading to intense vasoconstriction of vasculature
of skin, skeletal muscles, intestines and fat.
• It also selectively vasodilates cerebral, coronary and pulmonary vascular beds.
• Half life of 10-20 minutes
• Dose: 40 units bolus intravenously. To replace 1st or 2nd dose of epinephrine
Anti Arrhythmic Drugs
• Prolongs repolarization and refractoriness in the sino-atrial node, atrial and
myocardium, AV node and His-Purkinje cardiac conduction system.
• Dose: 300 mg IV rapid infusion diluted in 20-30 ml of saline followed by second dose
Amiodarone of 150 mg if needed.
Lidocaine
Magnesium
• VT that has not responded to defibrillation.
• May be considered if amiodarone is not available.
• Dose: 1-1.5 mg/kg initial dose followed by 0.5 to 0.75 mg/kg every 5 to 10 minutes
if needed. Maximum of 3 doses or 3mg/kg.
• Effective in terminating polymorphic VT or torsades de pointes.
• Dose: 1-2 gm infused over 5 minutes.
Drugs not recommended
Atropine
• Not included as a drug for PEA, Asystole in the new CPR-ECC guidelines.
• Use is retained for symptomatic bradycardia.
• Dose: 0.5 mg IV every 3-5 min to a maximum of 3mg
• Create extracellular alkalosis and inhibit oxygen release
• May produce hypernatremia and hyperosmolarity
• produces excess CO2, which freely diffuses into myocardial and cerebral cells and
Sodium
bicarbonate may paradoxically contribute to intracellular acidosis.
Calcium
• Routine administration of calcium for treatment of in-hospital and out-of-hospital
cardiac arrest is not recommended
Reversible causes
5 Hs
5 Ts
Hypovolemia
Toxins
Hypoxia
Tamponade
Hydrogen ion( acidosis)
Tension pneumothorax
Hypo/hyperkalemia
Thrombosis(pulmonary)
Hypothermia
Thrombosis(coronary)
Post Cardiac Arrest Care
after ROSC(Return of spontaneous circulation)
• Avoiding fever : Ischemic brain injury is aggravated by
increased body temperature
• Therapeutic Hypothermia: Can improve outcome in patients
who remain comatose after successful resuscitation of out of
hospital cardiac arrest.
– Cooling is begun within 1-2 hours after CPR
– Cooling blankets are used to achieve body temperature of
32-34 degree Celsius
– Sedation and neuromuscular blockade is used to avoid
shivering
Post Cardiac Arrest Care
after ROSC
– Hypothermia is maintained for no less than 12 hours
and no more than 24 hours
– Rewarming is passive
– Watch for Hyperkalemia or Hyperglycemia
• Glycemic Control: moderate glycemic control (140180mg/dl). Dextrose containing fluids should be avoided.
• Treat hypotension with fluid and vasopressors
ACLS Cardiac Arrest Circular Algorithm.
Neumar R W et al. Circulation. 2010;122:S729-S767
Copyright © American Heart Association, Inc. All rights reserved.
Differences in Pediatric and Adult Resuscitation
Infant (1-12 months)
Breathing Rate
Child (>12 months)
20 breaths per minute
Adult
8-10 breaths per
minute
Pulse Check
Brachial
Carotid
Carotid
Compression Rate
>100 per minute
100 per minute
100 per minute
Compression Method
2 finger chest
compression
Heel of one hand
Heel of both hands
Compression Depth
At least 1/3rd AP
diameter; about 1.5
inches (4 cm)
At least 1/3rd of AP
diameter; about 2
inches (5 cm)
At least 2 inches (5
cm)
Compression:
Ventilation Ratio
Foreign Body
Obstruction
30:2 (Single rescuer)
15:2 (Two rescuers)
Back blows and chest
thrust
Heimlich manoeuvre
30:2 (One or more
rescuers)
Heimlich manoeuvre
Modification in CPR in Pregnant
Females
• Position: Patient is put in left lateral position
• Chest compressions are done slightly above the
centre of the sternum
• Insert an advanced airway early in resuscitation to
reduce the risk of regurgitation and aspiration
• Rapid sequence intubation with continuous cricoid
pressure is the preferred technique for intubation
• Decide whether to perform emergency hysterotomy
• No modification in defibrillation
Changes in the new guidelines
I) The Change From "A-B-C" to "C-A-B“
Multiple valid reasons
• By changing the sequence to C-A-B, chest
compressions will be initiated sooner and
ventilation only minimally delayed until
completion of the first cycle of chest
compressions (30 compressions should be
accomplished in about 18 seconds).
• The highest survival rates from cardiac arrest
are reported among patients with a rhythm of
VF or ventricular tachycardia (VT). In these
patients the critical initial elements of CPR are
chest compressions and early defibrillation.
II) Removal of “ look - listen – feel’’
• Performance of these steps is inconsistent and time
consuming.
• For this reason the revised guidelines stress
immediate activation of the emergency response
system and starting chest compressions for any
unresponsive adult victim with no breathing or no
normal breathing (ie, only gasps).
III) Chest compressions
• Emphasis on higher "chest compression rates”.
The recommendation has been changed from
compression rate of "approximately 100/min" to
compression rate of "at least 100/min".
• The number of chest compressions delivered per
minute during CPR is an important determinant of
return of spontaneous circulation (ROSC) and
survival with good neurologic function.
• The recommendation for chest compression
depth has also been changed to "at least 2
inches (5cm)".
• Rescuers often do not push the chest hard
enough. Studies have shown that increasing
the depth of compressions is associated with
increased blood flow.
IV) Cricoid pressure
• Cricoid pressure can prevent gastric inflation and
reduce the risk of regurgitation and aspiration during
bag mask ventilation, but it may also impede
ventilation.
• Seven randomized studies showed that cricoid pressure
can delay or prevent the placement of an advanced
airway (e.g., endotracheal tube) and some aspiration can
still occur despite application of cricoid pressure.
• In addition, it is difficult to appropriately train rescuers
in use of the maneuver.
• Hence, revised guidelines do not recommend routine
use of cricoid pressure in cardiac arrest.
V) New "circular" ACLS algorithm
• The older 2005 "box and arrow" designed algorithm listed
key actions performed during the resuscitation in a
sequential fashion.
• The revised algorithm is simplified and streamlined, and is
"circular".
• Before 2005, ACLS courses focused mainly on added
interventions, such as manual defibrillation, drug therapy,
and advanced airway management, as well as alternative
and management options for special situations.
• In ACLS 2010, the emphasis is exclusively on high quality
CPR - the only thing which has consistently shown to work
and improve outcomes.
VI) Capnography
• 2005 guidelines only recommended CO2 detector
device to confirm endotracheal tube placement.
• Continuous quantitative waveform capnography is
now recommended for intubated patients throughout
the peri-arrest period.
VII) Atropine is 'out'; Adenosine is 'in'
• Atropine is no longer recommended for routine use
in the management of pulseless electrical activity
(PEA) and asystole.
• Evidence suggests that the routine use of atropine
during PEA or asystole is unlikely to have a
therapeutic benefit .
• Adenosine is recommended in the initial diagnosis
and treatment of stable, undifferentiated regular,
monomorphic wide-complex tachycardia.
VIII) Post-cardiac arrest care
• Post-Cardiac Arrest Care is a new section in the
revised guidelines.
• To improve survival a comprehensive,
multidisciplinary system of post-cardiac arrest care
should be implemented in a consistent manner.
• Treatments should include cardiopulmonary and
neurologic support, as well as therapeutic
hypothermia and percutaneous coronary
interventions (PCIs), when indicated.
• An electroencephalogram (EEG) for the diagnosis of
seizures should be performed with prompt
interpretation as soon as possible and should be
monitored frequently or continuously in comatose
patients after return of spontaneous circulation
(ROSC).
• The benefits of therapeutic hypothermia have been
reemphasized, based on two recent large studies.
Alternative techniques and devices
• Compared with conventional CPR, these
techniques and devices typically require more
personnel, training, and equipment, or they apply
to a specific setting.
• Rescuers should be trained to minimize any
interruption of chest compressions or
defibrillation and should be retrained as needed.
Techniques
1) High-Frequency Chest Compressions
• High-frequency chest compression (typically at a
frequency >120 per minute) has been studied as a
technique for improving resuscitation from cardiac
arrest and have demonstrated mixed results.
• The 2010 AHA Guidelines for CPR and
ECC recommend compressions at a rate of at least
100/min.
• However, high-frequency chest compressions may
be considered by adequately trained rescue
personnel as an alternative (Class IIb, LOE C).
2) Open-Chest CPR
• The heart is accessed through a thoracotomy
(typically created through the 5th left intercostal
space) and compression is performed using the
thumb and fingers, or with the palm and extended
fingers against the sternum.
• This technique generates forward blood flow and
coronary perfusion pressure that typically exceed
those generated by closed chest compressions.
• There is insufficient evidence of benefit or
harm to recommend the routine use of openchest CPR.
• However, open-chest CPR can be useful if
cardiac arrest develops during surgery when
the chest or abdomen is already open, or in
the early postoperative period after
cardiothoracic surgery (Class IIa, LOE C)
3)Interposed Abdominal Compression-CPR
• 3-rescuer technique
An abdominal compressor plus the chest
compressor and the rescuer providing ventilations
• Includes conventional chest compressions combined
with alternating abdominal compressions.
• The dedicated rescuer who provides manual abdominal
compressions will compress the abdomen midway
between the xiphoid and the umbilicus during the
relaxation phase of chest compression.
• IAC-CPR increases diastolic aortic pressure and
venous return, resulting in improved coronary
perfusion pressure and blood flow to other
vital organs.
• IAC-CPR may be considered during in-hospital
resuscitation when sufficient personnel
trained in its use are available (Class IIb, LOE
B).
4) “Cough” CPR
• The use of forceful voluntary coughs every 1 to 3
seconds shortly after the onset of a witnessed non
perfusing cardiac rhythm in a controlled
environment such as the cardiac catheterization
laboratory.
• Can generate systemic blood pressures higher than
those usually generated by conventional chest
compressions, allowing patients to maintain
consciousness for a brief arrhythmic interval.
• “Cough” CPR may be considered in settings such
as the cardiac catheterization laboratory for
conscious, supine, and monitored patients if the
patient can be instructed and coached to cough
forcefully every 1 to 3 seconds during the initial
seconds of an arrhythmic cardiac arrest. (Class IIb,
LOE C).
5) Prone CPR
• When the patient cannot be placed in the
supine position, it may be reasonable for
rescuers to provide CPR with the patient in the
prone position, particularly in hospitalized
patients with an advanced airway in place
(Class IIb, LOE C)
6) Precordial Thump
• New to the 2010 Guidelines and is based on the
conclusions reached by the 2010 ILCOR evidence
evaluation process
• The precordial thump may be considered for
patients with witnessed, monitored, unstable
ventricular tachycardia including pulseless VT if a
defibrillator is not immediately ready for use (Class
IIb, LOE C), but it should not delay CPR and shock
delivery.
Devices
• Devices to Assist Ventilation
1) Automatic Transport Ventilators
• The use of an ATV may provide ventilation and
oxygenation similar to that possible with the use of
a manual resuscitation bag, while allowing the
Emergency Medical Services (EMS) team to perform
other tasks (Class IIb, LOE C).
• Disadvantages include the need for an oxygen
source and a power source.
• Devices to Support Circulation
1) Active Compression-Decompression CPR
• Performed with a device that includes a suction cup to
actively lift the anterior chest during decompression.
• The application of external negative suction during the
decompression phase of CPR creates negative intra thoracic
pressure and thus potentially enhances venous return to the
heart.
• Meta-analysis of 10 studies involving both in-hospital arrest
(826 patients) and out-of-hospital arrest (4162 patients) and
several other controlled trials comparing ACD-CPR to
conventional CPR showed no difference in ROSC or survival.
2) Impedance Threshold Device
• The impedance threshold device (ITD) is a pressuresensitive valve that is attached to an endotracheal
tube, supraglottic airway, or face mask.
• The ITD limits air entry into the lungs during the
decompression phase of CPR, creating negative
intrathoracic pressure and improving venous return to
the heart and cardiac output during CPR.
• It does so without impeding positive pressure
ventilation or passive exhalation.
• The ITD and ACD-CPR devices are thought to act
synergistically to enhance venous return. During
ACD-CPR with or without the ITD, one randomized
study found no difference in survival, whereas
another randomized study found that the addition
of an ITD improved short-term survival (24-hour
survival and survival to ICU admission).
• The use of the ITD may be considered by trained
personnel as a CPR adjunct in adult cardiac arrest
(Class IIb, LOE B)